Health inspection·August 31, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of diet plans. Staff E. confirmed he spoke with the resident and let her know that they could not provide those types of items and thought that speaking with her at the time of interview meant they solved the complaint. He did not pass the complaint/grievance to the SW or NHA. He stated he did not think to pass those concerns along as he thought he took care of them with Resident #1 himself. He stated there was no documented evidence he had spoken with Resident #1 related to the concerns, and now believed he should have. On 8/31/2023 at 11:00 a.m. an interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B stated she remembered Resident #1 during her admission approximately one month ago and she did not have her specifically on her assignment but did hear she had complaints related to her television in her room and it may or may not have fell on the resident. Staff B. stated she heard Resident #1 had also complained about bugs in her room, her toilet not working properly and residents who were allegedly not being nice to her. Staff B. stated Resident #1 was always involved with her own care and had many complaints during her stay. Staff B. stated she never had Resident #1 on her assignment but heard of all these complaints made by her, from other floor staff. Staff B stated she had overheard staff to include the Director of Nursing (DON), Staff H., and the Maintenance Director talking about some of Resident #1's concerns but did not know if the concerns had been investigated, resolved, and communicated back to the resident. On 8/31/2023 at 1:25 p.m. the Nursing Home Administrator (NHA) stated while Resident #1 was admitted and during her stay, she did have concerns that were brought to the attention of the Social Worker (SW), but the SW failed to document each of the Resident's concerns, and failed to work the grievance/complaint process to include identifying each allegation/concern by way of initial communication with the resident, investigating each concern, ensuring each concern was worked with resolution and final communication to the resident. The NHA was aware Resident #1 had concerns with the television placement in her room, hall noise to include another resident's radio, and various food complaints. The NHA stated the previous SW did not identify and document these complaints, therefore they were not properly investigated and communicated back to the resident with resolution. The NHA could not find any paperwork that noted any of Resident #1's concerns. The NHA stated she believed the previous SW had either shredded the grievance documents or never had them completed in the first place. The NHA stated all voiced and or written complaints made by residents, family of residents, resident representatives and visitors all have to be documented to show they followed the grievance/complaint process. A review of the Grievance log provided by the NHA on 8/28/2023 revealed no documented grievances were recorded during the month of 7/2023 for Resident #1. 2) On 8/28/2023 at 9:32 a.m. Staff G, sitter was interviewed in Resident #2's room. Staff G stated she was hired by Resident #2's family member to sit in the room with the resident for thirteen hours a day, three days a week. Staff G stated she had just helped Resident #2 with his breakfast meal, and he usually takes a nap after breakfast. Observations revealed Resident #2 was lying in bed under the covers. He was noted to be resting quietly with his eyes closed. The room was completely dark. Staff G. stated she has in the past had concerns when arriving to sit with the resident around 7:00 a.m., during her shifts. She stated she would come in to the room to find Resident #2 not checked and changed after incontinence episodes, the room would not be cleaned from the day before, nurses would bring Resident #2 the wrong medication or wrong dose of medication and would find insects in the room. Staff G. revealed she had reported these issues first to Resident #2's family member and then to the nurse on duty and at times would speak to the DON. Staff G. stated she had reported these issues several times during the months of 6/2023, 7/2023, and 8/2023. Staff G stated no one from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 2 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility has ever come back to her with communication related to her complaints. She feels that staff in the facility never followed up with her, but they may have followed up with Resident #2's family member. On 8/28/2023 at 3:00 p.m. an interview was conducted with Resident #2's family member. The family member stated she had been having concerns with the facility for a number of months. The family member stated staff was not checking and changing Resident #2 during the night shift. She stated she had found many insects crawling throughout Resident #2's room. She stated staff was not providing Resident #2 with the right medications and the correct dose of medications. She stated Resident #2's room was always found filthy, soiled, and not cleaned from the day/night before. Resident #2's family member stated she had spoken with the previous NHA and the DON many times during the past few months with regards to the above-mentioned concerns and she has never had any follow up from them. Resident #2's family member revealed she never put in a written complaint as she felt her verbal concerns was good enough. Resident #2's family member stated she had no confidence in the DON because she would just tell her they she would investigate but never get back with her. Resident #2's family member confirmed none of the staff ever followed up with her with regards to her voiced concerns lodged back in 6/2023, 7/2023, and 8/2023, so she went ahead and voiced a new complaint and stated her father was being neglected from services to include provision of incontinence care. She stated she had found out if she complains of neglect, the facility has to do a report and investigation. Resident #2's family member stated the facility did follow up with her with regards to the neglect allegation and things with her father got better with checking and changing him during the night. However, Resident #2's family member stated management had not gotten back with her with regards to the investigation of wrong medications, wrong dose of medications, room soiled, and insects in the room. A review of Resident #2's medical record revealed he was admitted to the facility on [DATE]. Resident #2 had diagnoses to include, but not limited to: Parkinson's Disease, Pulmonary Fibrosis, Myoneural Disorder, dysphagia, disorder of the autonomic nervous system, heart disease, dementia, protein malnutrition, and hypertension. Resident #2 had a Power of Attorney (POA) in place to make both his medical and financial decisions. A review of the Minimum Data Set (MDS) assessments revealed the following: a. Quarterly, dated 4/27/2023 revealed; (Cognitive Abilities: BIMS score of 12, which indicated resident was cognitively intact. Activities of Daily Living ADL - Bed Mobility = Extensive Assistance with Two person assistance, Transfer = Extensive Assistance with Two person assistance, Dressing = Extensive Assistance with One person assistance, Eating = Supervision with One person assistance, Toilet use = Extensive Assistance with one person assistance, Personal Hygiene = Extensive Assistance with one person assistance, Bathing = Total Dependence; Bowel and Bladder - No catheter, No Urinary toileting program, always incontinent of bladder, always incontinent of bowel, Not checked as UTI during this assessment period. b. Quarterly, dated 7/25/2023 revealed; Cognition/BIMS score - 8 resident has declined cognitively since last MDS; Bowel and Bladder - No catheter, no urinary toileting program, always incontinent of bladder, always incontinent of bowel, Not checked as UTI during this assessment period. A review of the progress notes, dated 6/1/2023 - 8/28/2023, revealed the following: 6/3/2023 2:52 p.m. Social Service Note - Per resident daughter's no change are to be made to his medication unless resident's [family member]/DPOA is notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 3 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7/25/2023 8:06 p.m. Narrative - ADON brought DON an email written by a family member. Email stated neglect of her father being wet with urine in the morning from the weekend of July 22/23. She stated infestation of cockroaches in room. Notified administration and RNC [Regional Nurse Consultant] immediately, reported to [State Agencies and Local Police]. CNA [Certified Nursing Assistant] suspended, [Nursing Agency] notified, investigation started. The resident will be a two person assist with care. Skin assessment completed for possible skin breakdown; no skin breakdown noted. Resident will be a 06am change per facility policy. A review of the Grievance log provided by the NHA on 8/28/2023 revealed no documented grievance for Resident #2 for the months 6/2023, 7/2023, 8/2023. On 8/31/2023 at 1:25 p.m. an interview was conducted with the NHA. She stated she had been in constant contact with the Resident #2's POA (Power of Attorney), and she felt most of the concerns had been getting better or had been corrected. The NHA stated there had been a complaint with relation to neglect, specifically the resident alleged being left in wet clothes after an incontinence episode, during long periods of time during the night. The NHA stated they did an investigation reportable with regards to the neglect allegation. She stated the allegation of neglect could not be substantiated but they did do a total investigation and interviewed staff, other residents who receive incontinence care. The NHA stated she was aware of the resident's family member having concerns and complaints related to alleged insects in the room, concerns with medications not being provided appropriately and with the right dose. She stated the grievances had not been documented and appropriately investigated by first communicating back with the complainant. She stated the outcome of the investigation had not been communicated back to the family member. The NHA stated the facility should have documented these concerns and worked on their complaint/grievance policy and procedure. She continued to say the previous SW failed to document any of Resident #2's concerns and did not ensure the concerns were sent to the previous Administrator, or her, when she took over the building and therefore, the complaints/grievances were never followed up with. On 8/31/2023 at 1:00 p.m. the NHA provided the Resident and Family Grievance policy and procedure with a last review date of 8/14/2023, for review. The policy revealed the following. It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The Definitions section of the policy revealed; Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working towards resolution of that complaint/grievance. The Policy Explanation and Compliance Guidelines section revealed: 1. Name and title has been designated as the Grievance Official and can be reached at (list contact information). 2. There Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with State and Federal agencies as necessary in light of specific allegations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 4 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm 3. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. 4. Upon request, the facility will give a copy of this grievance policy to the resident. Residents Affected - Few 5. Information on how to file grievance or complaint will be available to the resident. Information may include, but not limited to: a. The contact information of the grievance official with whom a grievance can be filed, including his or her name, business address (mailing and email) and business phone number. b. The contact information of independent entities with whom grievances may be filed, this is, the pertinent State Agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program of protection and advocacy system. c. The time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievance. 6. Procedure: a. This facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of a grievance. b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. (i) Take any immediate actions needed to prevent further potential violations of any resident right. (ii) Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. c. Forward the grievance form to the Grievance Official as soon as practicable. d. The Grievance Official will take steps to resolve the grievance and record information about the grievance, and those actions, on the grievance form. (i) Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. (ii) All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance from to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievances and actively working towards a resolution of that complaint/grievance. e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 5 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm f. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: (i) The date the grievance was received. Residents Affected - Few (ii) The steps taken to investigate the grievance. (iii) A summary of the pertinent findings or conclusions regarding the resident's concern(s). (iv) A statement as to whether the grievance was confirmed or not confirmed. (v) Any corrective action taken or to be taken by the facility as well as a result of the grievance. (vi) The date the written decision was issued. 7. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 8. The facility will make prompt efforts to resolve grievance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 6 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a written Notice of Transfer and/or Discharge was issued in a timely manner for 5 residents (#7, #8, #12, #13, #14) out of 6 residents who were reviewed for transfer/discharge notification. Findings included: 1. A review of Resident #7's clinical record revealed an Administration progress note on 7/31/2023: sent to ED [Emergency Department] for trt [treatment] and evaluation. A Nursing Home Transfer and Discharge Notice was not able to be found nor was documentation found stating this notice was provided to the resident/resident representative within the medical record. Continued review of the medical record revealed Resident #7 was readmitted to the facility on [DATE]. 2. A review of the facility's admission/transfer log revealed Resident #8 was sent to the hospital on 8/23/2023 and had not returned to the facility as of 8/31/2023. The Nursing Home Transfer and Discharge Notice was not able to be found nor was documentation found stating Notice was provided to the resident/resident representative within the medical record. On 8/31/2023 at 11:30 AM a telephone interview with Resident #8 revealed he was still in the hospital, and he wanted to return to the facility. Resident #8 reported he does not know why the facility will not take him back. The resident reported he had not received any information or documentation from the facility relating to the transfer/discharge to the hospital. 3. A review of progress notes for Resident #12 revealed a health status note on 7/3/2023 at 7:52 AM which documented: This writer went in to assess patient and she complained of Shortness of Breath (SOB) and dizziness. Vital Signs 134/81, 02 86 @ 4 Liters per minute, temperature 97.7, Respirations- 104. Head Of Bed put to 90 degrees. Patient sent to [local hospital]. Doctor notified awaiting call back, emergency contact notified. Will notify oncoming 7-3 nurse. The Nursing Home Transfer and Discharge Notice was not able to be found nor was documentation found stating Notice was provided to the resident/resident representative within the medical record. 4. A review of Resident #13's progress notes revealed a nursing note, dated 7/15/2023 at 19:52; Resident was sent out to [local hospital] . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 7 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #13 was readmitted on [DATE] with the same diagnosis and transferred to the hospital again on 8/7/2023. The Nursing Home Transfer and Discharge Notice was not able to be found nor was documentation found stating Notice was provided to the resident/resident representative within the medical record for the 7/15/2023 and the 8/7/2023 transfers. 5. A review of Resident #14's progress notes revealed a note dated 8/21/2023 at 7:43 PM, Resident sent to [local hospital] .Being transferred from [local hospital] to [another local hospital]. The Nursing Home Transfer and Discharge Notice was not able to be found nor was documentation found stating Notice was provided to the resident/resident representative within the medical record. An interview was conducted on 8/28/2023 at 2:20 PM with Staff D, Licensed Practical Nurse (LPN). Staff D, LPN stated when a resident is sent out to the hospital, a packet is put together of paperwork to go with the resident. The paperwork is the resident's face sheet (demographics), medication listing, any current orders, current diagnostics (labs or x-rays), and a SBAR (Situation-Background-Assessment-Recommendation) which is a communication between the facility and the hospital. No other documents are sent. An interview was conducted on 8/28/2023 at 2:30 PM with Staff C, LPN. Staff C, LPN stated when a resident is sent out to the hospital, they are sent with their face sheet, medication listing, and current labs, if needed. No other documents are sent. An interview was conducted on 8/28/2023 at 10:16 AM with the admission Coordinator, who is filling in for the Social Services Director, as the facility currently is without. The admission Coordinator stated when a resident goes out to the hospital, nursing is responsible for giving the resident/resident representative any documentation. I am only responsible for admission documents to the facility. An interview was conducted on 8/31/23 at 10:59 AM with the Interim Director of Nursing (DON). She stated the expectation for residents' being sent out to the hospital is a transfer packet be completed. The transfer packet includes: the resident's face sheet, medication list, code status, bed hold policy, and the [State Agency] Nursing Home Transfer and Discharge Notice. She indicated the forms would be in the document sections of the medical records. On 8/31/2023 at 11:30 AM the Administrator was requested to bring any documents regarding bed hold policy and transfer and discharge notices for Resident #7, #8, #12, #13, and #14. No documents were received for the dates above by the time the survey team exited on 8/31/2023 at 4:00 PM. A facility policy titled, Transfer and Discharge (including AMA), with a reviewed/revised by date of 6/2-23 revealed the following: Date implemented: is blank. Date reviewed and revised: is blank. Policy: it is the policy of the facility to permit each resident to remain in the facility, not initiate transfer or discharge for the resident from the facility, except in limited circumstances. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 8 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Next subsection: Policy Explanation and Compliance Guidelines: 1. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facilities ability to meet the resident's needs. 5. Generally, the notice must be provided at least 30 days prior to the facility-initiated transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: a. the health and safety of individuals in the facility would be in danger due to the clinical or behavioral status of the resident, b. The resident's health improved sufficiently to allow more immediate transfer discharge, C. An immediate transfer discharge is required by the residents urgent medical needs, d. a resident has not resided in the facilities for 30 days. 6. in these exceptional cases the notice must be provided to the resident, resident's representative if appropriate and the long-term care ombudsman as soon as practicable before the transfer or discharge. 7. The facility will maintain evidence that notice was sent to the ombudsman. 8. If the information and notice changes prior to affecting the transfer discharge the social services director must update the receipts of the notices as soon as practical once up updated information becomes available. For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer discharge date in order to provide 30-day advance notification. 11. non-emergency transfers or discharges initiated by facility, return not anticipated. a. document the reasons for the transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facilities attempts to meet the residents needs and the services available at the receiving facility to meet the needs. Document any danger to the health or safety of the residents or other individuals that failure to transfer discharge would pose. b. Provide a transfer discharge notice to the resident representative and ombudsman as indicated. 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). a. Obtain physicians order for emergency transfer discharge, stating the reason the transfer discharge is necessary on an emergency basis. g. Provide a notice of transfer and the facilities bed hold policy to the resident and representative as indicated. h. The social service director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they must be sent when practicable such as in a list of residents on a monthly basis as long as the list meets all requirements for content of such notices. i. The resident will be permitted to return to the facility upon discharge from the acute care setting. j. In a situation where the facility initiates discharge while the residence is in the hospital following emergency transfer the facility will have evidence that the resident status at the time the resident seeks to return the facility meets one of the specified exemptions. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge, and also send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice to the Ombudsman will occur at the same time the notice of discharge is provided to the resident and the resident representative, even though at the time of the initial emergency transfer, sending a copy of the transfer notice to the Ombudsman only needed to go occur as soon as practicable. l. The resident has the right to return to the facility pending an appeal of any facility-initiated discharge unless the return would endanger the health or safety of resident or other individuals in the facility. The facility will document the danger that failure to transfer or discharge would pose. Event ID: Facility ID: 105419 If continuation sheet Page 9 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record and policy review the facility failed to ensure a written bed hold notice was issued in a timely manner for 5 residents (#7, #8, #12, #13, and #14,) out of 6 residents reviewed for transfer/discharge process. Findings included: 1. A review of the progress notes for Resident #7 revealed an administration note on 7/31/2023: sent to Emergency Department for treatment and evaluation. The Bed Hold Policy was not able to be found nor was documentation found to show the Bed Hold Notice was provided to the resident/resident representative within the medical record. Resident #7 was readmitted on [DATE] with the same diagnosis and transferred to the hospital on 8/20/2023. The record contained a Bed Hold Policy form with the date 8/18/2023 on the bottom (two days prior to the hospital transfer). The form documented: information was provided to: Resident #7, no resident or resident representative signatures were observed on the form. The form was signed by a staff member, with Copy sent with Transfer Paperwork typed on the bottom of the form. 2. A review of Resident #8's record revealed the resident was transferred to the hospital for an involuntary admission/evaluation on 8/23/2023. The Bed Hold Policy was not able to be found nor was documentation found to show the Bed Hold Notice was provided to the resident/resident representative within the medical record. 3. A review of the progress notes for Resident #12 revealed a health status note on 7/3/2023 at 7:52 AM which documented: This writer went in to assess patient and she complained of Shortness of Breath (SOB) and dizziness. Vital Signs 134/81, 02 86 @ 4 Liters per minute, temperature 97.7, Respirations- 104. Head Of Bed put to 90 degrees. Patient sent to [local hospital]. Dr. notified awaiting call back, emergency contact notified. Will notify oncoming 7-3 nurse. The Bed Hold Policy was not able to be found nor was documentation found showing the Bed Hold Notice was provided to the resident/resident representative within the medical record. 4. A review of Resident #13's progress note dated 7/15/2023 at 19:52 revealed Resident was sent out to [local hospital] . Continued review of the record revealed Resident #13 was readmitted to the facility on [DATE] and transferred to the hospital again on 8/7/2023. The record contained a Bed Hold Policy form with the date 7/1/2023 on the bottom. The form documented: information was provided to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 10 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Resident #13. The form contained no resident/resident representative signatures. The form was signed by a staff member, with Copy sent with Transfer Paperwork typed on the bottom of the form. No additional Bed Hold Policy or Notice information could be located in the medical record for the 7/15/2023 or 8/7/2023 hospital transfers. Residents Affected - Some 5. A review of Resident #14's progress note dated 8/21/2023 at 7:43 PM revealed, Resident sent to [local hospital] .Being transferred from [local hospital] to [another local hospital]. The Bed Hold Policy was not able to be found nor was documentation found to show the Bed Hold Notice was provided to the resident/resident representative within the medical record. An interview was conducted on 8/28/2023 at 2:20 PM with Staff D, Licensed Practical Nurse (LPN). Staff D, LPN stated when a resident is sent out to the hospital, a packet of information is put together to go with the resident. The paperwork is the resident's face sheet (demographics), medication listing, any current orders, current diagnostics (labs or x-rays), and a SBAR (Situation-Background-Assessment-Recommendation) which is a communication between the facility and the hospital. No other documents are sent. An interview was conducted on 8/28/2023 at 2:30 PM with Staff C, LPN. Staff C, LPN stated when a resident is sent out to the hospital the residents are sent with their face sheet, medication listing, and current labs, if needed. No other documents are sent. An interview was conducted on 8/28/2023 at 10:16 AM with the admission Coordinator, who is filling in for the Social Services Director, as the facility currently does not have one. The admission Coordinator stated when a resident goes out to the hospital, nursing is responsible for giving the resident and/or representative any documentation. She stated she was only responsible for admission documents to the facility. An interview was conducted on 8/31/23 at 10:59 AM with the Interim Director of Nursing. She stated the expectation for resident's being sent out to the hospital is a transfer packet be completed. The transfer packet includes: the resident's face sheet, medication list, code status, bed hold policy, and the [State Agency] Nursing Home Transfer and Discharge Notice. She indicated the forms would be in the document sections of the medical records. On 8/31/2023 at 11:30 AM the Administrator was requested to bring any documents regarding bed hold policy notices for Resident #7, #8, #12, #13, and #14. No documents were received for the dates above by the time the survey team exited on 8/31/2023 at 4:00 PM. A facility policy titled Bed Hold Notice Upon Transfer, date implemented December 20222, was reviewed and revised 08/2023 by Clinical Services. The policy documented the following: Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. Subsection titled: Policy Explanation and Compliance Guidelines: Bed Hold Notice Upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 11 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Transfer Level of Harm - Minimal harm or potential for actual harm 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide the resident and or the resident representative with written information that specifies: a. the duration of the state behold policy, if any, during which the resident is permitted to return and resume residents in the nursing facility, b. the reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed hold periods include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility: * the resident requires the services which the facility provides; * the resident is eligible for Medicare skilled nursing facility services or Medicare aide nursing facility services. 3. In the event of an emergency transfers of resident, the facility will provide within 24 hours written notice of the facilities bed hold policies, as stipulated in the states plan. 5. The facility will keep a signed and dated copy of the bed hold notice information given to the resident and/or resident representative in the residence file. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 12 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with a resident, facility staff, and hospital staff, and record review, to include the admission/discharge log, medical record review, and policy review, the facility failed to permit readmission for one resident (Resident #8) of two residents reviewed for transfer and discharge to the hospital. Findings included: A review of the facility's admission/discharge log revealed Resident #8 was discharged to an acute care hospital on [DATE] and had not returned to the facility as of 8/31/2023. A review of Resident #8's admission Record revealed he was originally admitted to the facility in March of 2022, with diagnosis to include but not limited to, paraplegia and history of assault by other bodily force (gunshot to the spine). A review of the complete medical record revealed no documentation of a transfer or discharge notice on or after the 8/23/2023 hospitalization, and no facility documentation to include a rationale for not readmitting Resident #8. On 8/31/2023 at 11:30 AM a telephone interview with Resident #8 revealed he was still in the hospital, and he wanted to return to the facility. Resident #8 reported he does not know why the facility will not take him back and stated, I have lived there for over a year, and nothing has changed. On 8/28/2023 at 4:02 PM, the Activity Director (AD) reported on 8/23/2023 the staff were setting up outside for water day. She stated, the residents started coming out early and some of them took water guns and were squirting each other. Resident #8 came outside to smoke as the activity was being held in the same location designated for smoking. The AD informed Resident #8 there was no smoking during the activity. She said, Resident #8 responded by yelling and asking where he was supposed to smoke. The AD stated, during the exchange, another resident squirted Resident #8 with a water gun and Resident #8 got upset and took the entire game and pushed it off the table. She said, Resident #8 was yelling at the different residents about squirting him. She stated they moved the activity away from Resident #8, and the police were called. She said Resident #8 calmed down and the police left. The AD stated, she later learned Resident #8 was transferred to the hospital under an involuntary admission by the physician. On 8/28/2023 at 2:43 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the resident had resided in the facility for over a year. She reported during this time, the resident has been known to yell at staff and be disruptive. The NHA stated on 8/23/2023 (the day of the transfer) the facility was having an activity outdoors involving water. The NHA said Resident #8 was splashed, became very angry, and because of this event, the facility's Psychiatric Nurse Practitioner decided to transfer Resident #8 to the hospital for an involuntary mental health evaluation. The NHA stated she began an investigation following the 8/23/2023 event, which determined other facility residents were afraid of Resident #8. The NHA confirmed no residents had approached facility staff to report any fear of Resident #8 and resident statements were taken because of the facility's internal investigation. The NHA stated the facility has refused to allow Resident #8 to return to the facility. The NHA stated she had not spoken to the Hospital Social Worker (HSW), but the Regional Business Development Manager (RBDM) has been communicating with the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 13 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/28/2023 at 10:16 AM, the admission Coordinator (AC) stated she was contacted by the hospital requesting Resident #8's readmission through an electronic communication system the morning of 8/24/2023, the day after Resident #8 was transferred. The AC stated she responded back via the electronic system informing the hospital the facility would not be admitting him back. The AC stated the HSW called her and stated the facility was required to readmit the resident because he had no medical or behavioral reason to be in the hospital. The AC stated she was unaware of any further contact with the hospital following that phone call. A telephone interview on 8/28/2023 at 3:03 PM with the HSW revealed she has been in contact with the facility every day, to no avail. She stated, There is no reason for him [Resident #8] to be in the hospital. The HSW stated Resident #8's behavior with the water activity may have been a trigger related to his gunshot wound as the activity had people shooting one another with water guns. The HSW reported Resident #8 had no behaviors from the time he was transported from the facility to current (8/28/2023). The HSW said she spoke with the NHA on 8/24/2023, the morning following Resident #8's arrival. The NHA told me the facility had to wait on two State Agencies to complete their investigations to determine if Resident #8 could be readmitted and those investigations take at least 5 days. The HSW stated, Whenever I call, there is always an excuse. The HSW read a note from the hospital's records, dated 8/27/2023, which documented, called and informed RBDM, Resident #8 has discharge orders. RBDM stated the facility will send someone out to the hospital for a face to face with Resident #8 on Monday, 8/28/2023. The HSW stated she spoke to the RBDM on 8/28/2023 and was told no one can come out as we have State in the building. The HSW informed the RBDM Resident #8 was cleared for readmission and the hospital physicians (internal medicine and psychiatrist) have documented Resident #8 was not in need of medication or any treatment. The resident was calm and had shown no behaviors or outburst. The HSW stated Resident #8 appeared bored and could not understand why the facility was refusing to readmit the resident, especially since a storm was coming. An interview on 8/28/2023 at 3:15 PM with the RBDM revealed the facility has been working with the HSW since 8/24/2023 and had informed the HSW that the facility was trying to figure out the interventions needed to allow for Resident #8's readmission or to assist the HSW with alternative placement. A follow-up telephone interview with HSW on 8/31/2023 at 11:00 AM revealed Resident #8 was still at the hospital. The facility was still refusing to take the patient back. The HSW stated the facility has stipulated Resident #8 can only return if he was placed on psychiatric medication and/or agrees to be followed by the facility's psychiatric provider and follow their recommendations. The HSW stated, the hospital psychiatrist will not place him on medication as he does not meet the criteria needed for medications. On 8/31/2023 at 11:30 AM the NHA was requested to bring any documents relating to the 8/23/2023 transfer and discharge notices for Resident #8. No documents were received by the time the survey team exited on 8/31/2023 at 4:00 PM. Review of the facility policy titled, Transfer and Discharge (including AMA) reviewed/revised by 6/2023 revealed the following: Policy: it is the policy of the facility to permit each resident to remain in the facility, not initiate transfer or discharge for the resident from the facility, except in limited circumstances. Next subsection: Policy Explanation and Compliance Guidelines: 1. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 14 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete meet the resident's needs. 5. Generally, the notice must be provided at least 30 days prior to the facility-initiated transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: a. the health and safety of individuals in the facility would be in danger due to the clinical or behavioral status of the resident, b. The resident's health improved sufficiently to allow more immediate transfer discharge, c. An immediate transfer discharge is required by the resident's urgent medical needs, d. a resident has not resided in the facilities for 30 days. 6. in these exceptional cases the notice must be provided to the resident, resident's representative if appropriate and the long-term care ombudsman as soon as practicable before the transfer or discharge. 7. The facility will maintain evidence that notice was sent to the ombudsman. 8. If the information and notice changes prior to affecting the transfer discharge the social services director must update the receipts of the notices as soon as practical once up updated information becomes available. For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer discharge date in order to provide 30-day advance notification. 11. non-emergency transfers or discharges initiated by facility, return not anticipated. a. document the reasons for the transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facilities attempts to meet the residents needs and the services available at the receiving facility to meet the needs. Document any danger to the health or safety of the residents or other individuals that failure to transfer discharge would pose. b. Provide a transfer discharge notice to the resident representative and ombudsman as indicated. 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). a. Obtain physicians order for emergency transfer discharge, stating the reason the transfer discharge is necessary on an emergency basis. g. Provide a notice of transfer and the facilities bed hold policy to the resident and representative as indicated. h. The social service director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they must be sent when practicable such as in a list of residents on a monthly basis as long as the list meets all requirements for content of such notices. i. The resident will be permitted to return to the facility upon discharge from the acute care setting. j. In a situation where the facility initiates discharge while the residence is in the hospital following emergency transfer the facility will have evidence that the resident status at the time the resident seeks to return the facility meets one of the specified exemptions. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge, and also send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice to the Ombudsman will occur at the same time the notice of discharge is provided to the resident and the resident representative, even though at the time of the initial emergency transfer, sending a copy of the transfer notice to the Ombudsman only needed to occur as soon as practicable. l. The resident has the right to return to the facility pending an appeal of any facility-initiated discharge unless the return would endanger the health or safety of resident or other individuals in the facility. The facility will document the danger that the facility failure to transfer or discharge would pose. Event ID: Facility ID: 105419 If continuation sheet Page 15 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to implement fall care planning interventions related to the placement of floor fall mats for one resident (#2) of seventeen sampled residents. Findings included: On 8/28/2023 at 9:32 a.m. Resident #2's room door was observed closed all the way and had a sign posted that read in marker handwriting DO NOT COME IN THIS ROOM. The sheet listed the specific times of not coming in the room. The sheet of paper was listed in both English and Spanish. The room was very dark, and the window blinds were closed making the room pitch dark. A visitor was observed in the room, who was identified as Resident #2's in house sitter, Staff G. Staff G stated she was hired by Resident #2's family to work thirteen-hour days at the facility, three days a week and on call as per the need for services. Resident #2 was observed lying in bed, under the covers, with the call light placed within his reach. He was observed resting with his eyes closed. A fall floor mat was positioned on the floor on the left side of the bed and no fall floor mat was on the right side of the bed. The right-side fall floor mat was observed leaning up against the wall near the room door. Staff G. stated when she is in the room, she will at times take the fall floor mat on the right side of the bed and place it up against the wall and keep it that way until she leaves for the day. She stated there are many times when she arrives at the facility at 6:45 a.m. to find both fall floor mats are leaning up against the walls and not placed on the floor next to the bed as they should be. She stated Resident #2's bed was not in the lowest position, and she comes in to find his bed is lifted up approximately two to three feet from the lowest floor position. Staff G. stated Resident #2 has a diagnosis of dementia, Parkinson's Disease, and is a fall risk. She did not know the last time Resident #2 had a fall at the facility, since his admission date. On 8/31/2023 at 5:48 a.m. an interview was conducted with Staff F, Licensed Practical Nurse (LPN). Staff F. stated she had been a floor nurse on Resident #2's unit for about two weeks. Staff F. confirmed she knew Resident #2 and was knowledgeable related to his care and services. Staff F. also confirmed she normally works the 11-7 shift and rounds the halls several times a shift to ensure the aides are providing services per care plans. She stated she ensures her staff are checking and changing residents if needed, at least twice a shift. At 5:55 a.m. Staff A, Certified Nursing Assistant (CNA), who had Resident #2 on her current 11-7 shift assignment, stated she had Resident #2 regularly on her assignment and she was knowledgeable of his service needs. She stated Resident #2 is totally dependent on staff for all Activities of Daily Living (ADL) tasks and confirmed he was a fall risk. She stated interventions that should be in place are for him to be in bed at its' lowest floor position, as well as fall floor mats to be placed and positioned on both sides of the bed. Staff A stated she had just checked on Resident #2 about thirty minutes prior. She did not remember the positioning of the bed or if the floor had floor mats on either side of the bed. At 6:00 a.m. both Staff A, CNA and Staff F, LPN opened Resident #2's door and the room was totally dark. Staff A. turned on the over the bed light to find Resident #2 resting comfortably with his eyes closed. The bed was observed not in its lowest position and was raised approximately two to three feet up from the floor. The right side of the bed floor was observed without a fall floor mat. A fall floor mat was observed leaning up against the wall near the room entrance door. Both Staff A and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 16 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff F confirmed the bed was not positioned in the lowest position and the fall mat was not placed on the floor on the right side of the bed. Staff A stated she could not recall if the mat was lying up against the wall the entire 11-7 shift or not. Staff F stated both the bed position was incorrect, and the floor mat should have been placed on the floor and not lying up against the wall, while the resident was in bed. A review of Resident #2's medical record revealed he was admitted to the facility on [DATE]. Resident #2 had diagnoses to include, but not limited to: Parkinson's Disease, Pulmonary Fibrosis, Myoneural Disorder, dysphagia, disorder of the autonomic nervous system, heart disease, dementia, protein malnutrition, and hypertension. Resident #2 had a Power of Attorney (POA) in place to make both his medical and financial decisions. A review of the Minimum Data Set (MDS) assessments revealed the following: a. Quarterly, dated 4/27/2023 revealed; (Cognitive Abilities: BIMS score of 12, which indicated resident was cognitively intact. Activities of Daily Living ADL - Bed Mobility = Extensive Assistance with Two person assistance, Transfer = Extensive Assistance with Two person assistance, Dressing = Extensive Assistance with One person assistance, Eating = Supervision with One person assistance, Toilet use = Extensive Assistance with one person assistance, Personal Hygiene = Extensive Assistance with one person assistance, Bathing = Total Dependence; Bowel and Bladder - No catheter, No Urinary toileting program, always incontinent of bladder, always incontinent of bowel, Not checked as UTI during this assessment period. b. Quarterly, dated 7/25/2023 revealed; Cognition/BIMS score - 8 resident has declined cognitively since last MDS; Bowel and Bladder - No catheter, no urinary toileting program, always incontinent of bladder, always incontinent of bowel, Not checked as UTI during this assessment period. A review of the current Physician's Order Sheet for the month of 8/2023 revealed the following: a. Floor mats on both sides of bed while in bed, every shift for preventive falls. The original order date was 10/31/2022. b. Suncoast Hospice related to end Stage diagnosis of Parkinson's. c. Transfers - Sit to Stand x 2 person. d. Bilateral Transfer Aides; Promote turning and repositioning with order date 7/25/2023. e. Low air loss mattress w/bolsters, check for proper place each shift for skin breakdown prevention. A review of the nurse progress notes dated 6/1/2023 - 8/28/2023 revealed the following: 8/7/2023 8:25 a.m. Narrative -This writer observed patients floor mats were leaning against the wall. This writer offered to place bilateral floor mats on the ground and lower bed height since patient was in the bed in a high position. Daughter stated, no since she was in the room and would not be leaving him. A review of the care current care plans with next review date 11/22/2023 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 17 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Risk for falls and fall related injuries related to cognitive loss and impaired mobility, Parkinson, weakness, with interventions in place to include but not limited to: Bilateral floor mats on both sides of the bed while in bed. - Risk for decreased ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, and toileting related to chronic disease process, impaired mobility, with interventions in place. - Risk for falling related to weakness and cognitive impairment related to diagnosis: Parkinson's, Lewy body Dementia, Dysphagia, with interventions in place to include but not limited to: Floor mats on each side while resident is in bed. On 8/28/2023 at 9:32 a.m. An interview was conducted with Staff B, LPN. Staff B stated Resident #2 was a fall risk due to his diagnosis of Parkinson's and Dementia. She could not remember the last time or if he did have a fall while admitted at the facility. She did confirm when he is in bed, and alone, the bed should be in the lowest position, and both fall floor mats should be positioned on the floor on either side of the bed. She revealed during her normal 7-3 shift hours, she usually tours and walks the floor and checks in with the residents to see if her aides have followed each of the [NAME] care plan interventions. Staff B was made aware Resident #2's bed was observed not to be in the lowest position and with one floor mat not in position on the floor. On 8/31/2023 at 1:25 p.m. the Nursing Home Administrator (NHA) confirmed though the family likes to remove the fall floor mats from the floor when they visit, the mats still should be on the ground, in place, when the resident is in bed. She confirmed when the resident is in bed during the night and not receiving an in-house sitter visit, the mats should be in place on the ground on both sides of the bed. On 8/31/2023 at 1:00 p.m. the Nursing Home Administrator provided the Comprehensive Care Plans policy and procedure with a last review date on 8/2023, for review. The policy revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy explanation and compliance guidelines section revealed. #3 The Comprehensive Care Plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. The resident's goals for admission, desired outcomes, and preferences for future discharge. #6 The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. #8 Qualified staff responsible for carrying out interventions specified in the care plan will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 18 of 19 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105419 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oldsmar 3865 Tampa Rd Oldsmar, FL 34677 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm notified of the roles and responsibilities for carrying out the interventions, initially and when changes are made. On 8/31/2023 at 1:00 p.m. the Nursing Home Administrator provided the Fall Prevention Program with last review date of 4/2023, for review. The policy revealed the following: Residents Affected - Few Each resident will be assessed for fall risk and will receive care and service in accordance with their individualized level of risk to minimize the likelihood of falls. The Definition section of the policy related to fall, revealed; A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. The Policy Explanation and Compliance Guidelines section revealed but not limited to. #3 The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. #5 High Risk Protocols: a. Provide patient centered interventions that address unique risk factors measured by the risk assessment tool: medications, psychosocial, cognitive status, or recent change in functional status. b. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive Devices ii. Increased Frequency of rounds iii. Low Bed iv. Fall Mat #6 Each resident's risk factors, and environment hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105419 If continuation sheet Page 19 of 19